Many fibromyalgia patients will tell you that it’s difficult to find a doctor like Stuart Silverman, M.D., who’s experienced in treating the disorder. With a team of practitioners, he’s spent most of his career listening to, diagnosing and helping people with fibromyalgia address every symptom, from muscle pain to brain fog. He answers questions from Lifescript on how to best manage the condition...

Stuart Silverman, M.D., has spent more than a decade decoding the multilayered chronic pain condition fibromyalgia – and he’s got a thousand metaphors to prove it.

“I tell patients they have a broken pain fuse,” he says. “The brain’s actually committing brain fraud in terms of how it’s processing sensations. It’s not only about pain, but about how touch, smell and sounds can also be misinterpreted.”

Silverman’s seen a lot of fibromyalgia patients, along with their varied and complex symptoms. He’s the medical director of both the Bone Center of Excellence at Cedars-Sinai Medical Center in Los Angeles and the Osteoporosis Medical Clinical Research Center in Beverly Hills, Calif., and a clinical professor of medicine and rheumatology at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA).

“We diagnose fibromyalgia not only by the widespread pain, but by the company of thugs it hangs out with,” Silverman says of fibromyalgia’s bedfellows, such as fatigue, brain fog and irritable bowel syndrome.

Over the years, Silverman has employed techniques that may not relieve all the pain, but certainly improve fibromyalgia patients’ quality of life.

“I view my role as a mentor or coach who gives them some direction on how they can take care of themselves better,” he says.

Read on as he shares information about common causes and triggers of fibromyalgia, as well as its latest treatments.

When should patients consider seeing a doctor for fibromyalgia?When they’re aware their pain is not simply in one area. For example, what you and I would perceive as a light touch on the thumb might be interpreted as being painful [by a fibromyalgia patient].

If that’s been going on for months and it’s everywhere – then you probably need to see a fibromyalgia specialist.

They may not be a rheumatologist, but a psychiatrist [for cognitive therapy] or rehab person [for physical therapy].

How do you confirm a fibromyalgia diagnosis?I ask people, “When your significant other or husband wants to give you a hug, are you concerned that wonderful hug could be painful to the touch?”

Those people need to come to our attention. They’re the people who say, “My husband and I have stopped hugging because it’s too painful. I love him dearly, but we don’t have that kind of intimacy anymore.”

It can affect a relationship that dramatically?With fibromyalgia, you not only can’t hug your husband or spouse, you have difficulty dealing with your children. So a woman might have problems role-playing as wife, mother and grandmother.

The dimensions of fibromyalgia are about pain and the biological reaction to it and the psycho-social havoc it wreaks on your life and how it interferes with your ability to make commitments to the workplace or your kids.

Do fibromyalgia patients usually give up being active?Patients say, “I’d like to get together with my daughter on Saturday, but it’s a 50/50 gamble whether I’ll have enough energy or be in too much pain to do that commitment.”

So they become increasingly isolated.

If setting the table causes pain in your shoulder, you stop doing it. Unfortunately, when you stop doing all those activities, you become de-conditioned [lose muscle strength].

And when you become de-conditioned, even ordinary activities like brushing your hair can become painful.

Does a person’s weight affect fibromyalgia?There’s increased prevalence among those with a higher BMI [body mass index]. So obese women are more likely to get it, but thinner women get it too.

Are there better tests to diagnose the disease now?Since 1990, we’ve had a good tender points exam.

Are tender points the painful areas?Right. In the last year, we’ve [developed] new criteria, but they haven’t replaced the original criteria, which is tenderness in 11 out of 18 points above and below the waist.

This adjunctive [additional] criteria allows primary care doctors to diagnose fibromyalgia by not only the widespread pain, but also by its bad group of neighborhood thugs: fatigue, thinking problems, dry eyes, dry mouth, sleep disorder, irritable bowel and irritable bladder.

If somebody tells me they have widespread pain and brain fog, along with alternating diarrhea and constipation, new studies show they probably have fibromyalgia, even if they don’t do the tender points exam.

In the past, many fibromyalgia patients’ symptoms were dismissed. How have things changed?There’s increased recognition of the disease. The problem is we thought of fibromyalgia only as a pain disorder.

But the primary care physician who saw patients with pain, fatigue, brain fog, sleep disorders, dry eyes and mouth and irritable bowel and bladder thought it must be an autoimmune disease, like lupus.

We now recognize that a chronic pain disorder is really neurological and affects you in a multi-systemic way. That’s been a major change.

What treatments are available?We have three medications [approved by the Food and Drug Administration] to reduce pain.

Lyrica and Cymbalta are two. Lyrica dramatically improves sleep – sometimes before it improves the pain.

Do all three medications work the same?Pain is multi-directional. There are ascending [nerve] pathways, which bring sensations to the brain. Lyrica acts on those pathways.

Then there are descending pathways [which send messages from the brain to lower parts of the body], and those can be controlled by [medications such as] serotonin-norepinephrine reuptake inhibitors, such as Cymbalta and Savella.

How do you decide which medications to prescribe?Most of my patients end up on at least two drugs because we need to cover both pathways.

We need to reduce the sensation or stimulus coming in [to the brain] and turn down the volume control knob by increasing the inhibitory pathway [which stops the brain from signaling pain to the body].

Cymbalta and Savella are antidepressants. Why prescribe them to fibromyalgia patients?Because they work on depression and anxiety as well as pain. Treating fibromyalgia as a combination of a chemical imbalance and pain seems to be the right path.

With Lyrica, you treat anxiety, sleep and pain.

How do you minimize side effects?We start with low doses because side effects are dose-related. By using the lowest dose, we can get the maximum benefit with minimal side effects.

Do you include other treatments with medication?We use cognitive behavioral therapy. If you have pain for two days, you might think: I’m going to have it the rest of my life.

Instead, we want you to cognitively say, “I know I have pain for two or three days, but I want to get better so I’m going to try to work through it.”

You also need support from a social network. It’s tough. It’s a very difficult disease to treat. It requires a whole team.

How important is exercise for fibromyalgia patients?They lose all confidence and ability for physical activity associated with pain. Therefore, it’s easier not to do anything.

I ask them, “Because of your pain, you’ve stopped doing anything and now you’re basically homebound, lying in bed. Do you walk out to the mailbox?”

They’ll answer, “Yes, I do that once a day.” So I suggest, “Can you walk out to the mailbox four times a day?”

You can break down exercise into smaller increments.

Why does this condition meet with so much resistance?It’s hard to convince your spouse or significant other that you’re ill when you don’t have abnormal blood tests or rashes.

It’s much easier if there’s a cast or a Band-Aid – something that gives a visual sign you’re not well.

For many fibromyalgia patients, friends and family don’t believe them. Some physicians don’t.

And there are some physicians that believe it but they don’t want any part of it – they actively screen out fibromyalgia [patients].

Why?To be honest, cost-efficiency.

Yet this is what you’ve chosen to do.Yes, but I do it with a full team. I’ve directed a whole fibromyalgia rehab team at Cedars for over 10 years now. I have a physical therapist and an occupational therapist.

Why is it necessary for a whole team of experts?On average, fibromyalgia patients are needy in so many domains.

Primary care physicians don’t have time in a 7-10-minute visit to talk about pain and fatigue, irritable bowel and bladder and the effects on quality of life and relationships.

We call fibromyalgia treaters people who have already organized a team to work with them. They don’t tackle it alone. It’s daunting. It’s too much for a single physician.

Docs feel more comfortable and confident with a team.

Do patients ever have a spontaneous remission?Studies have shown that about 3% will go into some remission over 2-3 years. My goal is to improve their ability to manage the disorder and pain.

How do you do that?We try to set functional goals, rather than pain goals. Our patients still have the same amount of pain, but we teach them that they can work through it and manage their lives.

Does simply getting the diagnosis help?It certainly does. The average patient who sees me now compared to 20 years ago has seen at least seven physicians before they get to me – and they’re in diagnostic cyberspace.

The first [task] is education.

I tell them, “Relax. You don’t have a tumor or cancer. This isn’t going to kill you. But it’s certainly wreaking havoc on your life. Let’s go back and see if there’s a way we can manage this better so we can give you back part of your life.”

That’s what patients want.

Do we know what sets off the condition?Fibromyalgia patients probably have an inborn problem with their pain management systems that emerges through a trauma, a motor vehicle accident or a period of stress.

In one case, a bank teller who had a gun to her head for two hours in a robbery blew her fuse. Another woman was buried at Toys “R” Us under 100 boxes of Barbie dolls and woke up with fibromyalgia.

Is there a genetic component to fibromyalgia?If your sister was depressed, your risk of depression is two or three fold. If your sister has fibromyalgia, your risk goes up eight fold.

Are new fibromyalgia treatments on the horizon?Yes. I’m involved with medical foods, a precursor to amino acids which replenish brain chemicals.

The interesting part about fibromyalgia pain management is learning how to balance the pharmacological and the non-pharmacological.

For many, the non-pharmacological treatments are just as effective as the pharmacological, which includes good nutrition, sun exposure, exercise and cognitive therapy.

This type of treatment demands a very good lifestyle. Most chronic diseases do.

Is the future for fibromyalgia patients optimistic?People should know that while we can’t get rid of pain, your quality of life and ability to function can improve despite the fibromyalgia.

We are just beginning to understand how to manage it better. But, you can only manage it as part of a team and probably the most important part of the team is the patient [who] buys into the concept that they’re going to get better.

When they say they want to get better and work with us, they usually do.

How Much Do You Know About Fibromyalgia?Fibromyalgia, described by Hippocrates in ancient Greece, is one of the world’s oldest medical mysteries. It is a complex illness marked by chronic muscle, tendon and ligament pain, fatigue and multiple tender points on the body. The disease affects about 2% percent of Americans, most of them women. How much do you know about fibromyalgia? Take this quiz and find out!

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